- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.01 / $1,835.00 / $5,091.00
| Facility | | $845.01 | $1,835.00 | $5,091.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,295.45 / $9,059.24 / $19,759.34
| Facility | | $4,295.45 | $9,059.24 | $19,759.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.44 / $1,384.44 / $3,268.83
| Professional | | $924.44 | $1,384.44 | $3,268.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,600.00 / $4,530.00 / $8,566.00
| Facility | | $1,600.00 | $4,530.00 | $8,566.00 |